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- a . <br /> [ r� <br /> 1• SHWAU <br /> Distance to Public Sewers Connection necessary: Yes N <br /> Does existing septic system earoP1Y with Ord. tt549 : Yes No <br /> Unknown If no, explain: <br /> De cribs se is in�stal�lation to 'be 'Led:,,,/, -46 <br /> E/�'�' <br /> 2 . WATER SUPPLY <br /> Is water supplied. by private we'll: es 4a re l roper•/ <br /> Yes �' No State clef ie.iency E� �✓' � r/EE�/ <br /> Does existing or porposed use mare this well public Water: Yes <br /> No..: Sample of well water taken: Yes NoDate taken <br /> Results Additional information or comment <br /> 3 . <br /> Licensed scavenger pick--up: Yes _,;'� No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MQSQUITQ QR VECTOR )UNTIAL <br /> State possibly: vector potentiftl necessary control: ' <br /> 5. QILET/BATE EAQUITES <br /> No. & location existing: �� Additional <br /> facilities needed <br /> $. PREVIOUS QPEiA1jQjJ HTISTORY. . <br /> ? . QN. <br /> State any problem, not previously noted: <br /> 8 . JjfjPLjLATI0P4 -DENS y / <br /> APpx. No. People per ..sq. . <br />